reducing the language accessibility GAP LANGUAGE SERVICES TORONTOs PROGRAM EVALUATION REPORTs CRICH Survey Research Units St. Michael’s Hospitals July 18, 2014s This evaluation was designed and conducted by the Centre for Research on Inner City Health (CRICH) Survey Research Unit (SRU) at the request of the Toronto Central LHIN (TC LHIN).

ABOUT TORONTO CENTRAL LHIN The Toronto Central LHIN is one of 14 regional authorities that are responsible for the planning, integration and funding of local health services. There are 170 health service providers in the Toronto Central LHIN that serve 1.15 million local residents and hundreds of thousands more who travel to this LHIN for care. LHINs are building a better health care system for people across Ontario by improving the patient experience in the health care system by working to remove the traditional silos between health care providers.

ABOUT THE CRICH SURVEY RESEARCH UNIT The CRICH Survey Research Unit is housed at the Li Ka Shing Knowledge Institute, St. Michael’s Hospital. The SRU was created in July 2009 to consolidate, mobilize and expand CRICH’s considerable survey research capabilities and expertise. The Unit provides research and evaluation services to the health and social science community. For more information visit: http://sru.crich.ca.

LEAD CONTRIBUTORS Dr. Patricia O’Campo, Kimberly Devotta, Dr. Tatiana Dowbor, Cheryl Pedersen

ACKNOWLEDGMENTS The CRICH SRU would like to thank the patients and providers who participated in the evaluation, as well as providers who assisted with participant recruitment. Your insight and support is much appreciated. We would also like to thank Amy Katz and Jennifer (Sears) Miniota for reviewing the report, Rebecca Brown for assisting with interviewing and recruitment and Kawsika Sivayoganathan for assisting with interviewing.

For more information about the evaluation please email [email protected]

Table of Contents

1. EXECUTIVE SUMMARY 4 2. INTRODUCTION 5

Program description Program stakeholders Use of over-the-phone interpretation services in the health care setting—what the literature says

3. EVALUATION METHODOLOGY 8

Phase 1 – Qualitative exploratory interviews Phase 2 – Quantitative surveys Provider survey Patient survey Evaluation strengths and limitations Privacy and approvals

4. EVALUATION RESULTS 11 Impact of Language Service Toronto on other sources and modes of interpretation Appropriateness of LST program as a mode of interpretation Impact on service delivery Provider and patient satisfaction Identified areas for improvement and expansion of the LST program

5. SUMMARY OF ANSWERS 25 REFERENCES 26 APPENDICES 27 1. Executive Summary:

Language Services Toronto Program Evaluation Report

In 2012, the Toronto Central Local Health Integration Network (TC LHIN) created the Language Services Toronto (LST) program to provide an initial group of community and KEY FINDINGS health care organizations with greater access to professional over-the-phone interpreters so all patients could access care regardless of the language they spoke. Following the The Language Services Toronto program first year of LST implementation, the TC LHIN identified the has a strong impact on service accessibility need to evaluate the program before expanding to more and patient autonomy for patients with organizations within and outside the TC LHIN. limited or no English skills. The Survey Research Unit at the Centre for Research on Inner City Health at St. Michael’s Hospital designed and The LST program promoted a significant conducted the evaluation using a mixed-methods approach to shift from the utilization of ad-hoc, capture the perspectives of both patients and providers (e.g. nurses, physicians, administrative staff and managers) since non-professional interpretation the program’s initial implementation in October 2012. Data options to professional over-the-phone collection took place between June 2013 and May 2014. Close interpretation services. to 90 per cent of organizations that used the LST program during the evaluation period are represented in the data. The majority of patients and providers currently utilizing the LST program are satisfied with the services offered and reported improvements in different aspects of health care encounters (e.g. relationship, comfort, privacy).

There is a need to continue to monitor service provision (e.g. wait times, languages offered, training materials).

There is a need to complement LST with other interpretation strategies (e.g. accommodations for people who are hard of hearing, in-person, video conference) for certain types of visits and patient needs. 2. Introduction

In July 2008, the Toronto Central Local Health Integration including 19 hospitals and 14 community agencies in the TC Network (TC LHIN) identified language as a systematic and LHIN and other neighboring LHINs. All health and community avoidable barrier to the equitable provision of health care ser- service providers, part of the TC LHIN coverage area, as well vices in Toronto. In 2010, the TC LHIN partnered with SickKids as providers from the surrounding LHIN geographies were to release a plan for action with the publication of the report invited to participate in the program, with funding committed Improving Health Equity through Language Access: A Model of for a small group of early adopter TC LHIN community-sector Integrated Language Services throughout Toronto central LHIN.ii organizations. Improved access to language supports was identified as a pri- ority in the Hospital Health Equity Plans, in the consultations for the 2010-2013 Integrated Health Services Plan – (IHSP-2), and also during the health equity consultation that took place in the TC LHIN in the spring of 2011. In October 2012, the TC LHIN launched the Language Services Toronto (LST) program to provide over-the-phone interpretation services to hospitals and community agencies within its network. After one year of implementation and with plans to expand the program, the TC LHIN engaged the Centre for Research on Inner City Health (CRICH) at St. Michael’s Hospital to conduct an evalu- ation. The evaluation was designed and conducted by the CRICH Survey Research Unit (SRU). The findings from this mixed-methods evaluation are presented in this report.

Evaluation questions Figure 1: Geographic area of the Toronto Central LHIN What was the impact of the LST program on the Prior to LST, hospitals within the TC LHIN had identified interpretation services offered? translation and interpretation services as an area to be Is over-the-phone interpretation an appropriate addressed in their health equity plans. Hospitals and other mode for the LST program? organizations within the TC LHIN had varying usage rates – in some cases, none at all – for interpretation services. What was the impact of the LST program on service The main objectives of the LST program are (1) to eliminate delivery? language barriers to accessing quality service and (2) to improve health outcomes by ensuring increased accurate Are patients and providers satisfied with the communication between providers and patients through the program? use of professionally-trained interpreters. What aspects of the program should be improved and/or expanded? “All patients should receive high quality care, regardless of the PROGRAM DESCRIPTION languages they speak or sign.” The Languages Services Toronto (LST) program provides -TC LHIN real-time, over-the-phone interpretation (OPI) services in 170 languages, 24 hours a day, seven days a week to clients LST provides on-demand access to telephone interpreters utilizing health care services in participating organizations. for various health and social service-related interactions. For The program launched in October 2012, with the first phase example, telephone interpreters can be used by a medical

5 secretary booking an appointment over the phone; a health Health Centres. Hospitals within the TC LHIN, as well as care provider answering a follow-up question over the phone; hospitals and organizations outside the TC LHIN area, benefit and a provider conducting an in-person appointment. Users can from the group rate and program coordination, but use their include intake workers, primary care providers, etc. own budgets to pay for the services.

Using a dual-handset device, speakerphone or teleconferencing phone feature, patients/clients with limited English can communicate with providers and other health care staff in their Program stakeholders preferred language. Services are accessed through one central phone number that is answered by the RIO Network (a division The TC LHIN leads the LST program as the executive of Access Alliance Language Services). Callers are prompted sponsor. to key in the needed language and are then transferred to a RIO interpreter if one is available. In the event that a RIO The University Health Network (UHN) is the interpreter is not available, callers are automatically transferred operational lead organization. It represents the to Language Line Services to be connected with an interpreter. consortium of participating sites, maintains the In the case of rare languages, to ensure availability, staff can service contract with the vendor and provides call ahead and pre-book an interpreter. Each organization is training to program users. provided with an access code when they sign onto the program. A steering committee provides oversight for The code is keyed in by providers when accessing the services the program as well as strategic direction. The and used to track organization usage and direct billing. committee is made up of member representatives of Through the program’s bulk purchase, the member organizations participating in the program, as well as organizations have access to lower per minute rates for the TC LHIN. interpretation services. The TC LHIN covers the cost for TC A larger consortium of member representatives LHIN health services providers in Community Support Services, from participating organizations also exists Community Mental Health and Addictions and Community to create a forum for sharing best practices and business updates. What the TC LHIN wants to Participating organizations include hospitals and achieve with the LST program community-based agencies. A list of organizations affiliated with the program at the time of the evaluation is provided in Appendix A. These i) Provide organizations without access the organizations serve patients with a variety of needs, opportunity to use interpretation services. including clinical and mental health, from diverse ii) Provide organizations with existing access a cultural and language backgrounds. greater opportunity to use interpretation services RIO Network, a division of Access Alliance Language by addressing the high costs that can often be a Services, provides over-the-phone interpretation deterrent to using them more freely; (OPI) services to the LST program. Access Alliance iii) Provide all organizations access to a larger range has also entered into an agreement with Language of languages during a longer period of availability; Line Services to accommodate additional languages or overflow from the RIO Network. In the LST iv) Test the utility and efficacy of OPI in different program scenario, the RIO Network answers the call settings (e.g. community support services, CHCs, and, when needed, will transfer clients to Language mental health and addictions). Line Services.

6 Organizations that have signed onto the program enter into involved in their care. Using telephone interpretation services a contract with the University Health Network (UHN), the instead of family and friends allows providers to access operational lead organization representing the consortium of professional and accurate interpretation.vi participating sites. Use of bilingual staff members USE OF OVER-THE-PHONE When professional interpretation services are unavailable or INTERPRETATION SERVICES IN THE at least not readily available, the burden of interpretation can iii,v HEALTH CARE SETTING—WHAT THE also fall on bilingual staff members. Studies have shown concern from staff and physicians regarding unbalanced LITERATURE SAYS workloads in group practices where a bilingual physician is Literature suggests that use of telephone interpretation overwhelmed with more patients because of other practice services in health care is characterized by a mix of benefits members not being bilingual and not using professional and challenges for both providers and patients. Even in interpreters.vii Additionally, Hammick, Featherstone and health care practices where interpretation services are widely Benrud-Larsonvi caution that when employees are used available and encouraged by regional policies, telephone for interpretation they can become too involved with the interpretation can often go unused and/or be substituted patient’s care as time progresses, making it increasingly by ad hoc non-professional methods of interpretation for difficult for them to maintain the role of a third party a number of different reasons, including an attachment to interpreter and not elaborate or add their own interpretations current practices.vi, xiv when communicating between patients and physicians.

Use of family members Contributions to privacy and confidentiality The literature shows that well-documented risks of using Most literature on the topic maintains that an over-the- family members as interpreters include inferior quality of phone interpreter does not compromise the confidentiality care and a greater likelihood to commit errors that can of a patient-provider exchange because neither the patient lead to clinical consequences.iii In an exploratory study of nor interpreter is visually or verbally identified to each language interpretation services, patients appeared to have other.viii When telephone interpretation is used instead an appreciation of the need for readily available professional of a third-party, in-person interpreter or staff member interpreters and also considered medical service without during a health care appointment, it can help patients adequate professional interpretation to be unacceptable feel comfortable disclosing sensitive information during practice.iv Health care sites with available telephone history-taking and throughout the consultation.ix,x Having a interpreters have also been shown to be perceived by patients telephone interpreter is also more advantageous for physical as providing a higher quality of care when compared to sites examinations because it provides the needed linguistic that were not able to provide such a service.xvii assistance without the physical presence of an interpreter in x Generally, patients do not prefer to use family or friends the room . as their interpreters, especially when there is a chance of sensitive and intimate disclosures.iv Patients have expressed Non-clinical use of interpretation in health concern over using loved ones as interpreters, especially care settings children, because it can compromise confidentiality, Telephone interpretation services are also proven to be privacy and even adversely impact family relationships.v effective and appropriate for non-medical tasks involved In cancer care, for example, family and friends who come in health care. Administrative, ancillary, and follow-up care to appointments as companions and become interpreters scenarios with patients who speak limited English can benefit during visits may find their interpreter role to be emotionally from the use of over-the-phone interpretation.xi Conference difficult if they are already a part of a patient’s cancer journey.iv calls and three-way calling with telephone interpreters also While many patients are accompanied by bilingual relatives provide an efficient way to make appointments with patients and friends, it is not usually their preference to have them when they are at home.xi

7 3. Evaluation Methodology

Limits and barriers to use of over-the-phone The evaluation was based on a two-phased mixed-methods interpretation approach. The selected approach was to start with open- ended qualitative interviews, which later informed the Over-the-phone interpretation is not without its limitations, development of close-ended surveys. Information collected however. Compared to having a face-to-face interpreter, from both phases was analyzed and is being reported telephone interpretation cannot support the writing of together. prescriptions and other medical instructions for patients.x When using a telephone interpreter, gestures, facial PHASE 1 – QUALITATIVE EXPLORATORY expressions and other nonverbal cues that can impact the interpretation and convey understanding, can be lost.xii INTERVIEWS Finally, when patients speak limited or no English, staff may Qualitative exploratory interviews were conducted to obtain require the help of an intermediary to identify the language an in-depth understanding of the perspective of program they speak before accessing a telephone interpreter. stakeholders and to gather relevant information to develop the quantitative survey questions. Semi-structured interviews Literature shows that barriers to using a telephone were conducted with managers, health care providers and interpreter can also include misconceptions in terms of the administrative staff at organizations that had used the LST impact it can have on the length of an appointment. When program, as well as those involved with program management they see telephone interpretation services as “too hard to at the TC LHIN. Due to interpretation logistics, the patients’ use” and/or “taking too long”, some providers will often perspective was not included in this phase1. Participants were use less appropriate methods for interpretation such as asked about their experience with the LST program from family members or accompanying friends.xiii More generally, program introduction through implementation, identifying this perception can lead to the view that over-the-phone the current state, process recommendations and overall interpretation is inconvenient and cumbersome to staff and assessment. Please refer to Appendix B for a list of questions providers.xiv Additionally, a more practical barrier to using from the interview guide. these services is the equipment and setup involved. Phone jacks, proximity to patients and wireless phones in patient The sample was purposively recruited to include small areas can determine the practicality of using a telephone and large organizations, organizations with different interpreter during an appointment.vii, xv,xvi usage patterns and different organization types (hospital, community health centre, mental health and addiction Studies have noted that a critical reason why many staff and services). One main contact was selected for each site. health care providers may not use the services is because Through purposive and snowball sampling2, additional they are unaware of the range of available services and how managers as well as health care providers and administrative to access them. In addition, literature shows that providers staff were nominated to participate in an interview. are at times unsure about the preparation interpreters have received for the role, their knowledge of medical terminology A total of 31 participants completed the qualitative interviews and their ability to maintain confidentiality.v from June to August 2013. Just over half of the participants (n=17) were health care providers, and the remaining were service managers (second largest group), administrative staff and TC LHIN staff. In order to represent organizations of varying size (e.g. small CHCs, large hospitals) and low-, medium- and high-usage of LST, nine health care sites were purposively selected to recruit managers, providers and administrative staff participants. All sites had at least one provider and one manager participate in the qualitative phase.

1 To avoid conflict of interest, the evaluation team decided not to use the LST services for data collection purposes.

2 Snowball sampling is a non-probability sampling technique, where existing research/evaluation participants recruit and or refer people they know to also participate in the research/evaluation. 8 Interviews were audio recorded. All data was transcribed their organization for 1 to 5 years, and 46 per cent of them verbatim and thematically analyzed. had been in their position for in that organization for 1 to 5 years. Eighty-five per cent of participating providers were female and 84 per cent of all provider respondents fell within PHASE 2 – QUANTITATIVE SURVEYS the age range of 25 to 54 (the largest age range was 25 to 34, The purpose of phase 2 was to further investigate the which made up 39 per cent of the sample). identified qualitative themes to understand the impact of the LST program, appropriateness for different types of care, and areas of satisfaction and needed improvement, while Patient survey including the patient perspective as well. The surveys were The patient survey contained closed-ended questions that designed and distributed to all sites that had signed on for asked patients about the impact of the program, their the LST program, to collect more generalizable data. The satisfaction with telephone interpretation and what they surveys were web-based, self-administered, and had close- would do if the program was no longer available. Please refer ended questions. Patients were also offered a paper version of to Appendix C for the full survey instrument. the survey as an alternative. The survey was translated into the top 104 languages accessed through the LST program at the time of the evaluation. Provider survey The provider survey contained closed- and open-ended In total, 41 patients completed the survey and represented questions about changes in communication strategies, usage of the LST program at 23 different sites. Patients frequency of usage, patient impact, care appropriateness, as reported all sites at which they had used LST and not just the well as program satisfaction and recommendations. Please one from which they received the survey information. Sixty- refer to Appendix D for the full survey instrument. one per cent of people had used the service at community health centres, 59 per cent at a hospital and 32 per cent at A total of 127 providers participated in the quantitative community support services5. survey, representing 88 per cent (30 of 34) sites that were signed on and using the LST program at the time of The majority of patients were female (78 per cent). Twenty recruitment. During recruitment and follow-up calls, it was five per cent were age 65 and over, 25 per cent were 45 to 54 determined that some of the sites that had signed up and and 27.5 per cent were 35 to 44. Most participants identified had recorded usage had not actually used LST with a patient as White/European (32 per cent), East Asian (26 per cent) and or client. These sites did not complete the evaluation and Latin American (16 per cent). The top languages preferred reduced the number of eligible sites from 38 to 34. by the survey respondents were Portuguese and Spanish, representing 22 per cent and 20 per cent respectively of the All health care sectors were represented by providers who patients in the sample. The next most represented languages participated in the survey, with 40 per cent from hospitals, 37 were Russian, Cantonese, Vietnamese and Korean. per cent from community health centres and the remaining 23 per cent from community support services with some community mental health and addictions representation3. The EVALUATION LIMITATIONS AND largest groups of participants were nurses and social workers, STRENGTHS representing 22 per cent and 16 per cent of the sample respectively. The rest of the sample was made up of doctors, Evaluation limitations dietitians, allied health professionals, case managers, care Providers and patients who answered the survey could be coordinators, technologists, administrative staff, management different from those who did not. For example, those who and other groups. Fifty-six per cent of providers had been at didn’t answer the survey may have been patients who were not literate in their mother tongue or didn’t feel physically

3 Numbers for community mental health and addictions organization 4 The top 10 languages accessed for the LST program, in order of frequency participation were too small to report (n<5) separately. They have been were Hungarian, Italian, Korean, Portuguese, Russian, Simplified Chinese combined with counts for community support services. (Mandarin), Traditional Chinese (Cantonese), Slovak, Spanish and Vietnamese.

5 Patients indicated all sites where they had used LST and not just the site that informed them of the survey. 9

4. Evaluation Results or mentally able to answer a survey. Providers who didn’t participate may not have used the service. Surveys were also “[LST] has made a world of offered less often in acute health situations, which would difference when it comes to impact the characteristics of the sample of patients and providers. communicating with my clients.

The evaluation does not include qualitative input from Not having to rely on my clients’ patients. Only quantitative information was collected from family and friends for interpretation this group due to interpretation logistics. ensures confidentiality and Evaluation strengths promotes autonomy.” All organizations that actively used the LST program during - Manager the evaluation were invited to participate and 88 per cent of these sites were represented. IMPACT OF LANGUAGE SERVICE Due to active input from LST consortium members and help from all participating organizations, the survey data TORONTO ON OTHER SOURCES AND incorporates the views of 127 providers and 41 patients who MODES OF INTERPRETATION have used the LST program. Survey data suggest that the introduction of the LST program as an option for interpretation led to a decrease in the The two-phase exploratory design made it possible to use of ad-hoc, non-professional and non-over-the-phone develop a survey instrument tailored to the LST program, as interpretation (OPI) communication strategies. it incorporated all the main themes that emerged from the qualitative interviews. “[LST] provides a vital service and supports the autonomy of the client to direct their own care needs. It reduces reliance on other family members whose viewpoints may or may not be PRIVACY AND APPROVALS shared with the client.” - Project coordinator All data was collected by SRU staff, anonymized and stored at St. Michael’s Hospital. The evaluation framework was reviewed and approved by the TC LHIN. Since the evaluation was a quality improvement initiative, St. Michael’s Hospital Assistance of family and friends: Before the introduction of did not require the evaluation to receive Research Ethics LST, assistance of family and friends was used by 52 per cent Board approval as the Tri-Council Policy Statement: Ethical of providers ‘often’ or ‘always’ (an additional 37 per cent Conduct of Research Involving Humans, 2nd edition outlines. reported using family and friends at least some of the time). The introduction of the OPI program has allowed patients the opportunity to schedule and attend appointments regardless of the availability of friends and family, and also gives providers greater confidence in the conversation. According to the providers, patients should never feel pressured to bring people to appointments they may not want there.

Assistance of other providers/staff: Of these non-OPI strategies, the assistance of other providers and administrative staff that speak the needed language showed a large decrease in frequency of usage, going from 35 per cent and 23 per cent respectively, to 16 per cent and 11 per cent. Providers explained that while they themselves or others in their department may often call upon other providers and 11 “When you’re pulling other nurses to come and translate for you, when you’re pulling housekeeping to translate for you, you’re pulling them from another patient. You’re pulling them away from their work.” - Health care provider “Using family members is clearly less than ideal because you don’t know the language skills of the family member. You don’t know what they’re translating; they’re not bound by any sort of ethical training. They don’t necessarily understand, they are not translating what implications might be and they really don’t have any accountability in terms of quality of interpretations. There are all kind of “They could be an admin assistant…but really have insufficient issues related to family interpretation.” - Manager capability to discuss things from a medical perspective… regular communications can be quite different than communication pertaining to medical issues.” - Health care provider

“If they don’t speak much English, and they have family, we connect, but there are situations if clients, they are newcomers, they were being abused, and they did not want to involve anybody, any friend, any family members, then it would be very important for them to communicate with us 52% directly, and using the OPI is very important.” - Manager

37% 35% Before LST program introduced Notable changes can be seen in seeking 24% 23% After LST the assistance other providers and staff program members, as well as the use of face-to-face introduced interpreters. 16%

11% 11% No 7% 4% data 6% 6% 3% 4% 4% avail- 2% 2% able

Assistance Assistance Assistance of Assistance Face-to-face Volunteer Referrals to Asking Other strategies of patient’s of other administrative of other professional language other agencies patients family and/ providers who staff who patients who interpreters interpreters to bring or friends who speak needed speak needed speak needed their own speak needed language language language interpreters to language appointments

Figure 2: Non-OPI strategies providers reported as ‘often’ or ‘always’ using before and after the introduction of the LST program

12 staff members to assist with a non-English speaking patient, Providers also highlighted the scheduling challenges of in- they recognized this was not the most efficient method. person interpreters. Seeking the assistance of a staff member was described more as a last resort option and not something considered to be fair to colleagues or always appropriate for the type of patient visit. “In terms of calling the interpreters face-to-face its always an It was also highlighted that staff could lack the necessary issue because we have to know ahead of time that we need an interpreter and quite often when we ask interpreters to knowledge of medical terminology information to properly come, those are the [patients] who really are dealing with a lot interpret. of issues in their own lives and they often don’t show up for appointments.” - Health care provider Assistance of face-to-face Interpreters: After the LST program was introduced, there was a decrease in the use of face-to- face interpreters, from 37 per cent to 24 per cent. While face- OPI has also made it more possible for non-bilingual to-face interpreters still remain the only appropriate method providers to care for the patients of bilingual providers in for certain health care encounters (e.g. demonstrating emergency and drop-in situations, distributing workloads and medication administration and explaining medical procedures increasing availability to patients. using organ models), OPI has begun to be a strategy that can be used in visits where the presence of a third-party could negatively impact the patient experience. “I’ve had a lot of pregnant women and a lot of new babies where the mom does not speak English and ““[Through the telephone] there’s no face-to-face contact. It’s anonymous. I haven’t seen one person having negative I think that it’s just really allowed attitude towards it. They’re all happy to have the service and we go over lots of personal issues if we talk about mental them the comfort that they know health or sexual health. They actually prefer to use phone so there is no …judgmental face in front of them.” - Health care if they drop in and their regular provider Spanish-speaking provider isn’t here that myself or the nurse can still see them, communicate with them “We can actually communicate with the patient whenever and provide them good care. They’ll we want now. Not if that interpreter [or] this interpreter, is available.” - Health care provider be able to get their concerns or their worries across too. ” Providers also explained the added convenience of OPI and - Health care provider appropriateness in emergency situations, when compared to in-person interpreters.

“Sometimes the interpreters won’t show up or we’ll have a last minute emergency. Somebody comes in and they don’t speak English. We can always get a phone interpreter. We can understand what the client needs.” - Health care provider

13 APPROPRIATENESS OF LST PROGRAM AS chronic care and mental health care were next, with 88 per A MODE OF INTERPRETATION cent, 86 per cent and 73 per cent respectively. Mental health care was shown as the type of health service where phone “[LST] is not appropriate for every interpretation services would be most often inappropriate (8 per cent). Providers explained that OPI is not appropriate client and every visit. It’s not a for patients experiencing paranoia or dementia as the voice without a physical presence can be difficult for patients weakness of the program, it’s just to understand and for providers to explain. Providers also the nature of needs and not every believed that building rapport is especially important when discussing sensitive mental health topics, and the need can be met by this program.” involvement of a third party interpreter that the client - Health care provider never physically meets can make establishing rapport more challenging. Language interpretation in mental health care While LST provides a professional interpretation option for also requires an understanding and knowledge of symptoms, patients and providers, it varies in its level of appropriateness episodes and patient history to sensitively interact with for different types of care. Overall, the majority of providers patients. A social worker provided an example of an found over-the-phone interpretation (OPI) to be appropriate, interpreter repeatedly seeking clarification from the patient, however the percentage of agreement varied by type of care. not recognizing that the patient was experiencing a delusion. Of the providers that said they do not use LST each time they Similarly for other types of care, providers cited situations need interpretation (n=39), 44 per cent responded ‘phone not where face-to-face interpreters would be more appropriate appropriate modality for type of visit.’ for specific types of visits. Some expressed hesitation in using OPI with older patients. Providers also mentioned that while OPI may not be appropriate for the appointment itself, it Said it was Said it was somewhat Said it was could at the very least be used to book the appointment as appropriate appropriate inappropriate well as to follow up with patients over the phone between appointments.

Supportive care n=93 90% 6% 3%

Acute care n=78 88% 10% 1% “It would be great if this program can expand into providing face-to-face interpreters as most of our clients need to Chronic 86% care n=80 13% 1% be provided with demonstrations on how much food is consumed, food portions, how the diabetes medications are being administered; unfortunately, over-the-phone cannot Mental health 73% 8% care n=85 19% accommodate for this sort of needs. Face-to-face would be the appropriate option.” - Health care provider Figure 3: Providers rated how appropriate OPI services were for each type of care. Ninety per cent agreed that LST was appropriate for supportive care—the highest percentage. Only 73 per cent agreed that LST was appropriate for mental health care.

Overall, most providers believed OPI services to be “This service is wonderful for young patients who speak non-English—for people who understand and grew up using appropriate for health care visits. Supportive care (e.g. technology. Many elderly people do not like to use technology, dietitians, pain and symptom management teams, spiritual and decline to use the IPOP altogether. The volume is also an needs, psychosocial care, etc.) ranked the highest with issue.” - Health care provider 90 per cent reporting OPI to be appropriate. Acute care,

14 IMPACT ON SERVICE DELIVERY Patient 78% engagement “A wonderful service which has n=124 22% increased our access and timeliness Patient’s 72% in reaching out to our clients in a comfort level 25% manner which makes them most n=122 3% comfortable and able to participate Your 71% in the arrangement of their care.” relationship with your - Health Care Provider patients 29% n=124 Both patients and providers indicated that the program had a positive impact on service provision. Figure 4 shows that The disclosure 68% of patients (e.g. 84 per cent of providers reported an overall improvement do you feel they 30% in care, and 85 per cent of patients reported that the overall provide a more quality of their visit and service provided had improved. or less complete history?) n=120 2%

improved no change got worse “Clients are most comfortable if they communicate in their primary language.” - Administrative staff Figure 5: Providers reported improvements in engaging patients and their relationsips with them

Your comfort 76% Patients and providers both reported a substantial impact level during the on patient engagement and relationship with health care visit n=38 13% providers, with 68 per cent to 78 per cent of providers (see Figure 5) and 68 per cent to 76 per cent of patients (Figure 6) 11% reporting improvement. Your relationship 68% Providers: with your The overall 84% provider (e.g. 27% quality of the doctor, nurse, care provided 16% social worker) 5% n=122 n=37

Patients: The 85% improved no change got worse overall quality of your visit/ 7.5% service provided Figure 6: The majority of patients believed their relationship n=40 7.5% and comfort has improved with the use of LST

improved no change got worse The majority of patients and providers also reported an increase in patient privacy due to the implementation of the Figure 4: Overall, patients and providers both believe quality program (see Figure 7). of care has been improved with the use of LST

15 For patients, using the LST program during their appointment 67% has positively impacted aspects that reach beyond their visit Providers: Patients’ privacy 29% and health care encounter. n=121 4%

“It has fundamentally changed who we are able to offer 51% services to.” - Health care provider Patients: Your privacy 37% n=35 11% Your 87% understanding improved no change got worse of information given during 5% appointment Figure 7: Both patients and providers were asked n=39 8% about the impact of LST on patient privacy

Your likelihood 84% of asking Strong positive impact was also reported regarding patient questions 5% accessibility and autonomy, with 73 to 78 per cent of the during the visit n=38 providers (see Figure 8) and 72 to 87 per cent of the patients 11% (see Figure 9) indicating improvement. Your likelihood of 82% recommending the health care organization 13% 78% to friends and family Patients’ who speak the same autonomy n=121 language n=39 5% 22% Your ability to 75% Patients’ 73% schedule follow- access to your up or future organization appointments 18% n=122 27% on time n=40 8% improved no change got worse Your ability to 74% Figure 8: The majority of providers reported that LST has had a follow health positive impact on the autonomy of their patients and access to care care provider’s instructions 18% n=38 8% Providers believed ‘bigger picture’ impacts of having and using OPI to be an improvement in patient autonomy, as well Your likelihood of 72% as access to their organization. disclosing more information to your health care provider 18% n=39 10% “Interpretation is really important for maintaining the health of the individuals in the community. It is very important that improved no change got worse they understand instructions really well, and that they express what they want to tell physicians really well to be able to get Figure 9: Patients who used LST reported improvement in different good health care.” - Manager areas related to their capabilities during their health service visit

16 17 For patients, the largest decreases (around 10 per cent) were PROVIDER AND PATIENT SATISFACTION shown in privacy, comfort, likelihood to ask questions and Both surveys showed that most patients and providers disclosure of information. The patient data suggests that were satisfied with the Language Services Toronto program. for some patients, LST can have a negative impact on their Ninety-three per cent of providers said that they were health encounter experience and ability to engage with satisfied overall with the LSTprogram and 85 per cent of their provider to discuss information, supporting the earlier patients reported overall satisfaction with the telephone presented findings that while LST is a valuable asset it is not interpretation they experienced. appropriate for every patient. 7% dissatisfied 7% neutral Impact if program was cut Patients: Overall, how satisfied are you with the telephone 85% of patients satisfied “I think it might be a lifeline that interpretation? n=41 Providers: Overall, how satisfied are you with the Language 93% of providers satisfied is cut, because communication is Services Toronto program? n=125 everything for us.” 4% neutral - Health Care Provider 3% dissatisfied Both patients and providers were asked about the impact to Figure 10: Both patients and providers were asked how satisfied they themselves and their organization if the LST program was no were with the overall program of telephone interpretation longer available. Eighty-one per cent of providers agreed that it would lead to an increased difficulty in engaging patients. Providers explained that, for some patients, it could even Patients also reported high satisfaction levels regarding their mean no longer being able to see them at their organization. relationship with health care providers and their comfort level Providers also believe that a decrease would be seen in both during the appointment. the quality (74 per cent) and efficiency (71 per cent) of care. 5% dissatisfied 10% neutral

Your comfort level “There’s a few clients that I don’t know how we would go during appointments 85% satisfied about seeing each other [without the LST program], they don’t n=41 have anyone who could translate for them and they don’t Relationship with doctor speak English and for them I don’t know what we would do. or health care provider 93% satisfied They wouldn’t be able to access care.” - Health care provider n=41 5% neutral 2% dissatisfied Figure 11: Most patients reported satisfaction in the areas of ‘com- The most largely supported option (49 per cent) for patients fort’ and ‘relationship’ (n=41) would be to ask family and friends to provide needed interpretation if they no longer had access to LST. Some I’m satisfied with the program, because I think it is giving us patients also said they would have to find a health care the opportunity to have accessibility and just provide better provider who speaks their language (32 per cent) and/ services, like I said. So, I think that, anytime that you can or stop going to the organization and find one that offers increase accessibility, especially to clients that maybe are interpretation (20 per cent). For both patients and providers, isolated because of their situation…or their language is holding them back and is a barrier, I think that that’s a good thing.” no longer having LST would compromise their relationship - Health care provider and in some cases, ability to give and receive care.

18 Providers highlighted the importance of patient understanding and communication during the appointment, as well as 2% 2% 2% 2% 6% 3% building rapport to better their relationships with patients. 3% 6% 6% 8% 5% 14% “[LST is a] very efficient service. Very user-friendly, and I am confident that what I ask or say to the client is being repeated in the chosen language verbatim. Allows me to initiate home 95% 92% 92% 91% 89% 83% care services in a timely manner with the confidence that the client understands the process and the system.” - Health care provider

High levels of satisfaction (76 to 90 per cent for patients and Quality Profes- Availability Confi- Wait Technol- of inter- sionalism of inter- dentiality times ogy and 83 to 95 per cent for providers) were also reported for the pretation of inter- preters in of inter- n=124 equip- interpretation services itself and the equipment utilized to n=124 preters needed pretation ment access the service. n=124 languages n=118 availabil- n=124 ity n=122 satisfied neutral dissatisfied 5% 5% 5% Figure 13: Most providers also reported satisfaction with the interpretation service and needed equipment 10% 10% 7% 10% 5% 5% 5% 2% 7% 10% 15%

90% 90% 90% 88% 83% 83% 76% Higher neutral responses were reported regarding the providers satisfaction with the program leadership and supports (22 to 42 per cent), indicating that on these topics, compared to others, more providers were “neither satisfied nor dissatisfied” with the program. Dissatisfaction was consistently low (1 to 6 per cent) and satisfaction ranged from 55 to 72 per cent. Providers spoke highly of the training webinar and said subsequent demonstration Your Your Your Quality Profes- Timely Quality ability to confi- under- of inter- sionalism access to of tele- of the service was helpful and beneficial for understanding communicate dence in standing pretation of inter- inter- phone how the program worked. It was, however, highlighted that with the interpre- of infor- preters preters equip- what was missing from training was a follow-up session doctor or tation mation ment health care provided post-implementation. Additionally, providers positively commented on the availability of written instructional satisfied neutral dissatisfied material for program utilization, but also the need to be selective in what their organization could use. One manager Figure 12: Patients reported high levels of satisfaction in many areas highlighted the need to take those materials and adapt them related to the interpretation service and equipment (n=41) to the specific needs and services of each site.

19 “When you’re just starting a service you don’t know what questions really to ask because it’s kind of like you’ve got your blinders on and in retrospect there was probably a lot of questions that I would ask after six months being into the service.” - Manager “Hospitals coming together and working wherever we can to find common ground, and to share our pain but also to share our gain, kind of thing. It’s just it’s made it you don’t feel so alone. I mean, I don’t feel alone I feel like at any time I could e-mail somebody in the consortium and say ‘Help,’ you know. So there is that kind of relationships that form and both formal “[We] use the reference documents but we certainly and informal relationships” - Manager massage them or certainly change them a little bit to fit our organization because that, you know, they’re guidelines and then there’s kind of our own institutional processes that we also had to take into account.” - Manager

“I think it was a bit of a challenge because it is a very big group [the consortium]… there are some similarities but there are a lot of differences between the agencies” - Manager

Training to use the 72% 22% program n=116 6%

Program coordination/ 70% management 29% 1% It was expressed that the University Health Network n=101 (UHN) is responsive in their role as program coordinator. The consortium, as a gathering of different organizations, Program reference 63% 34% materials n=105 3% was found to also be particularly useful as a way of sharing best practices and coming up with solutions. It was also Program leadership 55% 42% highlighted, however, that the many variations amongst the n=92 2% group made coordination seem challenging.

Providers believed the fact that the LST program is a TC LHIN satisfied neutral dissatisfied initiative added credibility to the program and encouraged uptake amongst staff and providers at their organization, as “the LHIN gives us some clout” (Manager). Some concern, Figure 14: Providers were asked to rate their satisfaction with pro- gram leadership and support given to their organization however, was expressed related to the fact that the TC LHIN covers the costs of LST for certain organizations while other organizations cover OPI out of their budgets.

“UHN as being the admin, have done an absolute fabulous job about being available for questions.” - Manager

20 IDENTIFIED AREAS FOR IMPROVEMENT Convenience of other methods: Fifty-one per cent (n=20) of AND EXPANSION OF THE LST PROGRAM providers who don’t use LST for all language interpretation More than two-thirds (69 per cent) of providers surveyed needs cited the ‘convenience of other method’ as being the reported that they use LST every time they need language main reason for little-to-no usage of the program. Providers interpretation to communicate with non-English or limited- gave examples of accompanying family members and friends, English speaking patients. existing volunteer interpreters on duty, available providers and staff, as well as getting by with gestures and miming, as more ‘convenient’ ways of interpretation that deterred them Do you use LST every time from using the program. interpretation is needed? Patient preference: Providers reported that low usage of LST was also a result of patient preference. Patients may find it easier to use the person who accompanied them 31% to the appointment, for example, and in some cases they said bring people for that reason. Providers also explained that 69% “no” sometimes patients become impatient during the dialing said n=39 “yes” and connection process and would rather attempt to get by n=88 with limited English, gestures and simplified questions. Often patients with limited English feel they know enough to get through the conversation.

If no, why not? Technology or equipment challenges: While the introduction to LST has provided organizations with greater opportunities to access over-the-phone interpretation services, sites are 51% still figuring out how to develop the technical and equipment 44% capacity necessary to make sure the program is available 28% 23% 23% 18% every time it is needed. The location of telephones relative 8% to the patient examination area was one identified challenge. “If I’m at the exam table doing a blood pressure and I’m Other trying to speak and the telephone is on the desk with the speakerphone. Sometimes the interpreter is having a hard Convenience of Technology or to interpreter other methodfor type Patientof visit preference Cost of interpreter Wait time to connect time hearing us so we’re kind of yelling across the room to Phone not appropriate equipment challenges them.” (Health care provider) Shortage of speakerphones, phone jacks and dual handsets were also cited as examples Figure 15: Providers were asked if they use LST every time they of barriers to usage. “I like the services provided once I needed interpretation to communicate with a patient. Most provid- can access them. It is just often technically difficult at my ers said ‘yes’, while 31 per cent said ‘no’. The bar graph shows their institution to find a room with the proper equipment to have reasons for not accessing it every time. a proper three-way conversation.” (Health care provider)

In recognition of these challenges and the value of the Why not use LST? program, some organizations are, however, responding to Of the 31 per cent who reported not using the program each improve the technology and equipment capacity of their time they needed a language interpreter, the top reasons patient areas so the program can be used more often. “We’ve were convenience of other methods; phone not appropriate [now] offered them at this point four different phone options, modality for type of visit; the patient’s preference for from, you know, to using their Blackberrys and how they communicating using a different strategy; and challenges would do that. To a cordless to, a cordless conference phone, with technology and equipment. so we’ve gone around to try to address that issue around equipment.” (Manager)

21 Wait time to connect to interpreter: For some, the wait time for a specific language or the steps involved in connecting to an Top suggested improvements for OPI through RIO or Language Line (e.g. keying in language and access code) can be a deterrent to always using OPI. LST program 1. Quicker connection to interpreter (26 per Areas for improvement cent of providers suggested this) Quicker connections to interpreters by further streamlining the connection process was chosen as the top area of needed 2. Improve training of interpreter improvement. It was suggested that RIO increase its portfolio 3. Time to brief interpreter of languages and interpreters so fewer calls are transferred to Language Line Services. Other suggestions included a live 4. Decrease cost jump after 30 minutes (22 operator instead of an automated system and the transfer of per cent of providers suggested this) information that’s already been keyed in directly to Language Line Services.

Improve training of interpreters and time to brief interpreters were also top suggestions for the current LST program. Additional suggested Providers felt that, at times, interpreters lacked the needed medical training and knowledge to be effectively worked improvements for LST program into appointments. This most often occurred in the context of mental health care in cases where interpreters may not 1. Increased availability of number of understand or know the patient’s current health and past interpreters (13 per cent of providers history. suggested this) 2. Option to choose gender of interpreter “[interpreters] need to be aware that some people they’re 3. Increased availability of languages offered translating for are not going to be making sense … I hear the patient say something that probably doesn’t make sense and 4. Availability and visibility of needed then I hear a silence, and then I hear the translator try again to equipment (10 per cent of providers make them make sense. …. Whereas what I’m actually wanting to hear is the thing that doesn’t make sense, so that I can draw suggested this) my own conclusions.” - Health care provider

breastfeeding at one point and it was a male interpreter and I think that made her a bit uncomfortable. (…)We couldn’t really discuss it, because we would be using him to discuss it, but it might be helpful to have that option for something like Providers also felt that they were not always given that.” (Health care provider) enough time to brief the interpreter on the nature of the appointment, purpose of involving them and relevant patient history before introducing them into the three-way Ideas for expansion of program conversation. The top suggestions for expansion of the program were accommodations for people who are hard of hearing, Option to choose gender of interpreter was also highlighted inclusion of face-to-face interpreters and an expansion to as an aspect of interpretation that is sometimes needed video options. to sensitively and effectively work with an over-the-phone interpreter during an appointment. As one provider Providers felt that if the structure, organization and explained, “I was doing counselling with a mum around streamlining of the LST program was applied to other interpretation strategies, they and their patients could

22 benefit. “… face-to-face because I think it will bring down cost in the same way. We’re paying for it anyways. We’re spending “The dollars are going up so we need to look for ways to an awful long time with different agencies trying to get work together not with only within organizations but across organizations and not only within the same sector but interpreters so it’s a resource issue because, you know, it’s very across different sectors... we have CHCs, Community Service tough to coordinate. I think if that was streamlined in some way Agencies, hospitals; fabulous that we are coming together to I think it would save us some time and money.” (Health Care figure out efficiencies on how to provide service…we really Provider) need to figure out as an organization how we can work together rather than against each other or compete against Providers also showed support for expansion of the program each other. So, I think you know, in the long-run this has been beyond their own organization. Thirteen per cent believed the fantastic.” - Manager LST program should be expanded to specialists that are not part of the program already.

Expanding to specialists and other sites appeared to be a needed requirement for continuation of care and the overall impact of not only the care the provider was a part of, but also Expanding to sites was also viewed as beneficial to some the additional care they prescribe when they refer someone providers, as it could encourage greater collaboration and elsewhere. partnerships.

Top suggested ideas for expansion

1. Accommodations for people who are hard “When people go to see specialists, they need interpretation as well, and that service is not available. Because when you of hearing (31 per cent of providers suggested send somebody, like, we’ve had, on multiple occasions, we’ve this) had to pay for an interpreter to go to the surgeon’s office with the client. Because you want them to understand a procedure, 2. Include face-to-face interpreters if they’re going to have a procedure, or, the process, or, whatever that specialist is talking about.” - Manager 3. Expansion to video (20 per cent of providers suggested this)

Additional suggested ideas for

“It’s the continuity of our work. When we have clients that we expansion send, either to hospitals, we know that some of the hospitals are part of this initiative. So, we are happy when they are, but 1. Expansion to specialists (13 per cent of we serve a huge number of non-insured clients, and we are providers suggested this) funded to pay their bills as well. So, when those clients go to obstetricians or go to heart specialists, or, you know, they need 2. Program expansion to other sites (4 per that interpretation, because, we get a report back, we need to cent of providers suggested this) follow up on their situations.” - Manager

23 24 5. Summary of Answers

What was the impact of the LST program on the interpretation services offered? The program promoted a significant shift from using ad-hoc, non-professional interpretation options (e.g. patient family/ friends, administrative office staff, other providers, etc) to professional over-the-phone interpretation services that patients and providers felt comfortable using.

Is over-the-phone interpretation an appropriate mode for the LST program? YES, for the majority of needs. According to the patients and providers using the program, OPI is accessible, offers privacy and provides an opportunity to bridge the gap in communication, while providing professional and reliable interpretation of medical information. Appropriateness levels reported were high, ranging between 73 per cent and 90 per cent depending on the type of care provided. Mental health service had the highest inappropriate rate (8 per cent). Other interpretation modes are still required to meet specific patient needs (e.g. in the context of some encounters related to mental health, to demonstrate medical equipment, for sign language interpretation).

What was the impact of the LST program on service delivery? Besides the expected positive impact on the communication gap between patients and providers, the program also had a strong positive impact on service processes (e.g. improved patient-provider relationship, increased comfort and privacy levels) and interim outcomes (e.g. increased ability to schedule follow-up appointments and follow health care providers’ instructions, increased likelihood to disclose information and ask questions). According to the patients and providers using the program, the overall quality of care improved after LST program implementation, positively impacting patient autonomy and health care accessibility.

Are patients and providers satisfied with the program? YES, the satisfaction rates reported for patients and providers were very high: 85 per cent of the clients and 93 per cent of the providers reported being satisfied with the program. For patients, the higher satisfaction rates were associated with the impact on their relationship with the health care provider (93 per cent) and the lowest satisfaction rates were associated with the quality of the telephone equipment available (76 per cent). For the providers, the higher satisfaction rates were associated with the quality of interpretation (95 per cent) and the lowest satisfaction rates were associated with program coordination, leadership, training and quality of reference materials (55 to 72 per cent).

What aspects of the program should be improved and/or expanded? The main suggestions for improvement were quicker connection to interpreters, improved training of interpreters and time to brief interpreters. The main suggestions for expansion were accommodations for people who are hard of hearing, inclusion of face-to-face interpreters and inclusion of video conference. Providers also commented on the need to expand to other organizations, including the specialists they refer patients to, in order to ensure the continuity of a patient’s health care across organizations.

25 References

i Gardner, B. (2008). Health Equity Discussion Paper. speaking consumers: A review of strategies in Health Care Settings [Review]. Journal of Health Care for the Poor and ii SickKids. (2010) Improving Health Equity Through Underserved, 9, S40-S61. Language Access: A model for integrated Language Services Through the Toronto central LHIN. xiii Ramsey, K. W., Davis, J., & French, G. (2012). Perspectives of Chuukese patients and their health care providers on the use iii Atkin, N. (2008). Getting the message across—professional of different sources of interpreters. Hawai’i Journal of Medicine interpreters in general practice. Australian Family Physician, & Public Health: A Journal of Asia Pacific Medicine & Public 37, 174-176. Health, 71,249-252.

iv Jones, D., Gill, P., Harrison, R., Meakin, R., & Wallace, P. xiv Huang, Y. T. & Phillips, C. (2009). Telephone interpreters in (2003). An exploratory study of language interpretation general practice—Bridging the barriers to their use. Australian services provided by videoconferencing. Journal of Family Physician, 38, 443-446. Telemedicine &Telecare, 9,51-56. xv Bonacruz, K. G. & Cooper, C. (2003). Barriers to the use v Gerrish, K., Chau, R., Sobowale, A., & Birks, E. (2004). of interpreters in emergency room paediatric consultations. Bridging the language barrier: the use of interpreters in Journal of Paediatrics & Child Health, 39, 259-263. primary care nursing. Health & Social Care in the Community, 12, 407-413. xvi Brach, C., Fraser, I., & Paez, K. (2005). Crossing the language chasm. Health Affairs, 24, 424-434. vi Hammick, M., Featherstone, C., & Benrud-Larson, L. (2001). Information giving procedures for patients having xvii Krugman, S. D., Parra-Roide, L., Hobson, W. L., Garfunkel, radiotherapy: A national perspective of practice in the United L. C., & Serwint, J. R. (2009). Spanish-Speaking Patients Kingdom. Radiography, 7,181-186. Perceive High Quality Care in Resident Continuity Practices: A CORNET Study. Clinical Pediatrics, 48, 304-310. vii Gadon, M., Balch, G. I., & Jacobs, E. A. (2007). Caring for patients with limited English proficiency: the perspectives of small group practitioners. Journal of General Internal Medicine, 22, Suppl-6.

viii Hsieh, E. (2006). Understanding medical interpreters: reconceptualizing bilingual health communication. Health Communication, 20, 177-186.

ix Chan, Y.F., Algapan, K., Rella, J., Bentley, S., Soto-Greene, M. & Martin, M. (2010). Interpreter Services in Emergency Medicine. The Journal of Emergency Medicine, 38(2), 133-139.

x Masland, M. C., Lou, C., & Snowden, L. (2010). Use of communication technologies to cost-effectively increase the availability of interpretation services in healthcare settings. [Review]. Telemedicine Journal & E-Health, 16, 739-745.

xi Price, E. L., Perez-Stable, E. J., Nickleach, D., Lopez, M., & Karliner, L. S. (2012). Interpreter perspectives of in-person, telephonic, and videoconferencing medical interpretation in clinical encounters. Patient Education & Counseling, 87, 226- 232.

xii Riddick, S. (1998). Improving access for limited English-

26 Appendix A: Organizations signed onto LST during evaluation

1. Access Alliance Multicultural Health and Community Services 2. Alzheimer Society of Toronto 3. Baycrest Centre for Geriatric Care 4. Bridgepoint Health 5. Canadian Mental Health Association - Toronto 6. Central Toronto Community Health Centre 7. Centre for Addiction and Mental Health (CAMH) 8. Flemingdon Health Centre 9. Four Villages Community Health Centre 10. Guelph General Hospital 11. Holland Bloorview Kids Rehab 12. Hospital for Sick Children (SickKids) 13. Humber Community Seniors’ Services Inc. 14. Humber River Regional Hospital 15. Jean Tweed Treatment Centre 16. Mount Sinai Hospital 17. North York General Hospital 18. Parkdale Community Health Centre 19. Providence Healthcare 20. Regent Park Community Health Centre 21. Rouge Valley Health System 22. Salvation Army Toronto Grace Health Centre 23. South Riverdale Community Health Centre 24. St. Joseph’s Health Centre 25. St. Stephen’s Community House 26. Stonegate Community Association 27. Storefront Humber Inc. 28. Taddle Creek Family Health Team 29. Toronto Central Community Care Access Centre (Toronto Central CCAC) 30. Toronto East General Hospital 31. Unison Health and Community Services 32. University Health Network (UHN) 33. West Park Healthcare Centre 34. West Toronto Support Services for Seniors 35. William Osler Health System 36. Women’s Health in Women’s Hands 37. Women’s College Hospital 38. WoodGreen Community Services

27 Appendix B: Qualitative interview guide

Appendix B: List of Questions from the qualitative interview guide

Qualitative Interview Guide Question Managers Providers Administrative Qualitative Interview Guide Question Managers Providers Administrative Page Staff Page Staff Objective: To understand the objective of the program and to assess and inform the level of commitment to Objective: 3 To understand the level of satisfaction with the program 1 the program 20. Overall, how satisfied are you with the program? 1. Can you tell us a little about how you came to know about    • [P] Are you satisfied with the interaction you have had the program and describe your involvement with it? with the interpreters?    2. Please name the top 2 reasons why you think this initiative is    o Have you had any unpleasant interactions with important. an interpreter? Objective: To understand the comparison with not having access to the services • [P] Are you satisfied with your interaction with the client 3. Before implementation of the program, what strategies did while using the interpretation services? you use for dealing with non-­‐English speaking patients?    • [A] What about the process of scheduling the service? • How do you compare these strategies with what is 21. For what type of patients do working you feel this is really offered today with the program? well, for example, specific cultures or languages?    Objective: To understand the impact of the program • [P&A] Do the services work well for the first visit when compared with a follow-­‐up visit? 4. [M&A] What are the top 2 impacts of the program on your organization or services? Objective: To understand the satisfaction with the program from the providers’ perspective and the indirect [P] From your perspective, what are the that top 2 impacts    client perspective the program has had? 22. From your perspective, how do you think the interpretation    • On organizations? services have impacted client satisfaction? • On patients? • Do you have a particular story that comes to mind that would illustrate that? 5. [M] Remembering back before the interpretation services were offered, how have the interpretation services changed 23. From your perspective, please describe how the your organization? interpretation services have impacted client adherence or    • How does it affect the providers’ time? understanding of information from providers? [P] Remembering back to before the interpretation services • Can you give examples? were offered, how have the interpretation services changed    Objective: To understand the strengths and weaknesses of the program your daily work? 24. What you do think are the top two strengths of the program?    • In what ways? 25. Can you name 2 weaknesses of the program?    • Has having the services changed your workload or daily Objective: To understand suggestions for improvement and new users introduced to the program schedule in any way? 26. Do you have any suggestions for improving the program?    • Has it changed the quality work of your in any way? • Why do you feel that should be addressed? • How does having the services affect the patient’s privacy? 27. Do you have any suggestions or tips for institutions that are 6. [M] If the program was cut, what would be the impact to not involved with the program yet, but that will be introduced to    your organization or services? the program in the future? • Would you pay for the services yourself? Objective: To understand recommendations for expansion of the program [P] If the program was cut, what would be the impact to your    28. Would you recommend expanding the program to other areas services? and organizations? • On funding? • Your peer organizations? • On quality? • Across the province?    [A] If the program was cut, what would be the impact to your • Within your organization? services? • Training other staff members on the services? 7. How does the utilization of interpretation services affect the    29. Would you recommend expanding the services to include a organization’s budget? video option or something else similar to that?    8. How does Qualitative the program Interview affect Guide Question your workload? Managers Providers Administrative  • Translated discharge documents or other documents? Staff 30. If you Qualitative had a Interview limited budget, Guide Question which expansion Managers Providers Administrative  9. What proportion of your population requires interpretation    recommendations would prioritize? you Staff services? 31. That completes the questions that I have to ask. Is there Page Objective: To understand the utilization patterns of the program anything else about the program that you would like to add that    10. Are you accessing the service every time you need to? hasn’t been discussed? 2 • [NO]: Why aren’t you accessing the services?    • [NO]: What would need to change for you to use it every time you need to? Objective: To understand the process of implementing and carrying out the program 11. Are you responsible for identifying the language that the client speaks?    • [YES]: How do you do that? 12. Are you responsible for scheduling the interpretation    services? 13. [M&A] Can you list a barrier you’ve encountered while trying to implement or manage the service? • Do you have any suggestion on how to overcome this barrier?    [P] Have you encountered any barriers to using the service? • Do you have any suggestions overcome on how to this barrier? 15. Did you attend a training session on how to use the services? • [NO]: Would you have found that helpful? Would you attend? • [YES]: Did you find the training appropriate? How so? • [YES]: Do you use a document or protocol that outlines    the process for using the services?

• [YES]: Was the document given to you or did someone at your organization create it? • [YES]: Do you think anything was missing from the training or did you get what you needed? 16. Does your organization have a protocol or a guide to determine the process of identifying the need for interpretation    and scheduling the interpreters? • [YES]: What is included in the guide? 17. Are you a member of either the Language Services Toronto Consortium or Steering Committee? • [YES]: What do you see as the most valuable part of your    role on it? • [YES]: What valuable contributions have they made? 18. Do you find the governance and management of the program    appropriate? 19. Do you feel you can have your questions answered when needed?    • [NO]: What additional avenues would help?

28 1.2 What would you do if the telephone interpretation services are not offered anymore by the organization where you received it? (check all that apply)

 Ask a friend/family member to help me with interpretation  Stop going to the organization and find another one that offers interpretation  Try to understand what providers say without the help of interpreters Appendix C: Patient survey  Find a health care provider who speaks my language  Don't know  Other Please specify:

Appendix C: Patient and Provider Surveys

Telephone Interpretation Services Evaluation: Section 2 - Satisfaction Page Page 1 Patient/Client Perspective 3 2. Please rate your level of satisfaction with the following during appointments that involved the telephone interpretation: Thank you for agreeing to participate in this survey. We are interested in learning about your Very Satisfied Neither Dissatisfied Very No experience with over-the-phone language interpreters during your visits to health care sa tisfie d satisfied nor dissatisfied response dissatisfied providers, to find out what is working well and what could be improved with the program. This Quality of interpretation       survey should take approximately 5 minutes to complete. All responses are confidential and will not be linked back to you in anyway nor reported to any health care provider. Upon completion Professionalism of interpreters       of the survey, you will be offered the chance to provide your name, email address and phone number to be entered in a draw to win an iPad mini. Timely access to interpreters      

      A. Are you 18 years of age or older? Confidence in interpretation

 Yes Quality of telephone equipment        No

Have you completed this survey before? B. Relationship with doctor or health        Yes care provider  No C. Have you used a telephone interpreter while visiting a health care provider in the past year? Your understanding of information        Yes provided during appointments  No Please select the organization(s) where you have used a telephone interpreter (check all that Your comfort level during       apply): appointments  Access Alliance Multicultural Health and  Regent Park Community Health Centre Community Services Your ability to communicate with the        Alzheimer Society of Toronto  Rouge Valley Health System doctor or health care provider  Baycrest Centre for Geriatric Care  Salvation Army Toronto Grace Health Centre  Bridgepoint Health  South Riverdale Community Health Centre Overall, how satisfied are you with        Canadian Mental Health Association - Toronto  St. Joseph's Health Centre the telephone interpretation?  Central Toronto Community Health Centre  St. Stephen's Community House  Centre for Addiction and Mental Health (CAMH)  Stonegate Community Association  Flemingdon Health Centre  Storefront Humber Inc. Page  Four Villages Community Health Centre  Taddle Creek Family Health Team  Guelph General Hospital  Toronto Central Community Care Access 4

Centre (Toronto Central CCAC)  Holland Bloorview Kids Rehab  Toronto East General Hospital Section 3 - Demographics  Hospital for Sick Children (SickKids)  Unison Health and Community Services  Humber Community Seniors' Services Inc.  University Health Network (UHN) 3.1 What is your gender?  Humber River Regional Hospital  West Park Healthcare Centre  Male  Jean Tweed Treatment Centre  West Toronto Support Services for Seniors  Female  Mount Sinai Hospital  William Osler Health System  Transgender  North York General Hospital  Women's Health in Women's Hands  Other  Parkdale Community Health Centre  Women's College Hospital  No response  Providence Healthcare  WoodGreen Community Services 3.2 What is your age?

 18-24  25-34 Page Section 1 - Impact  35-44

2  45-54 1.1 We are interested to know how using the telephone interpretation service impacts different aspects  55-64 of the health care services provided to you. Please remember back to a time when you had a health  65+ care appointment without an interpreter. Please compare this health care appointment with the service  No response you received when the telephone interpretation service was provided. 3.3 What is your preferred language? How has having the telephone interpretation service impacted:  Cantonese  Hungarian  Significantly Increased Neither Decreased Significantly No Italian increased increased decreased response  Korean nor  Mandarin decreased  Portuguese       Your comfort level during the visit  Russian  Slovak Your privacy        Spanish  Vietnamese Your relationship with your provider        Other (e.g. doctor, nurse, social worker)  No response Please specify: Your likelihood to disclose more       ______information to your health care provider 3.4 Which racial or cultural group(s) do you belong to or identify with? (check all that apply)  Black/African (e.g., Kenyan, Jamaican, American) Your likelihood to ask questions        East Asian (e.g., Chinese, Japanese, Korean) during the visit  Indigenous/Aboriginal (e.g., First Nations, Métis, Inuit, Maori, Quechua)  Indo-Carribean (e.g., Guyanese with origins in India) Your understanding of information        Latin American (e.g., Argentinean, Cuban, Salvadorian) given during an appointment  Middle Eastern/West Asian (e.g., Egyptian, Iranian, Lebanese)  South Asian (e.g., Indian, Pakistani, Sri Lankan) Your ability to follow health care        South East Asian (e.g., Malaysian, Filipino, Vietnamese) provider's instructions  White/European (e.g., English, Italian, Russian)  Mixed heritage (e.g., Black and White) Your ability to schedule follow-up or        Other future appointments on time  No response If 'mixed heritage', please specify: Your likelihood to recommend the       ______health care organization to your friends and family who speak the If 'other', please specify: same language ______

The overall quality of your       If you would like to be entered into a draw to win an iPad mini, please provide the following visit/service provided information:

Name: ______1.2 What would you do if the telephone interpretation services are not offered anymore by the organization where you received it? (check all that apply) Email address: ______

______ Ask a friend/family member to help me with interpretation Page Telephone number:  Stop going to the organization and find another one that offers interpretation 5  Try to understand what providers say without the help of interpreters  Submitted information will only be used to determine and contact the winner. Find a health care provider who speaks my language  Don't know  Other Thank you for completing the survey. Please hit the SUBMIT () button and you will be Please specify: redirected to the web page for the Survey Research Unit, St. Michael's Hospital.

29 Section 2 - Satisfaction

2. Please rate your level of satisfaction with the following during appointments that involved the telephone interpretation:

Very Satisfied Neither Dissatisfied Very No sa tisfie d satisfied nor dissatisfied response dissatisfied Quality of interpretation      

Professionalism of interpreters      

Timely access to interpreters      

Confidence in interpretation      

Quality of telephone equipment      

Relationship with doctor or health       care provider

Your understanding of information       provided during appointments

Your comfort level during       appointments

Your ability to communicate with the      

doctor or health care provider

Overall, how satisfied are you with       the telephone interpretation?

Appendix D: Provider survey

1. Before implementation of the Language Services Toronto Program in November 2012, how Page LANGUAGE SERVICES TORONTO PROGRAM Page often did you use each of the following strategies for dealing with non-English speaking 1 patients? EVALUATION SURVEY 3 Sometime No Provider Perspective Never Rarely s Often Always response Assistance of patient's family and/or nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj friends who speak needed language

Assistance of other providers who speak nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj needed language

Assistance of administrative staff who nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj speak needed language

Assistance of other patients who speak nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj needed language Other phone interpretation programs nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj The Language Services Toronto Program wants to hear from service providers that have Face-to-face professional interpreters nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj experience using the telephone interpretation services in the . This short survey is part past year Volunteer language interpreters nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj of a program evaluation initiative sponsored by the program and coordinated by the CRICH Survey Research Unit at St. Michael's Hospital, designed to understand how well the program is Referrals to other agencies nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj doing. The overall evaluation includes qualitative and quantitative data collection phases and Asking patients to bring their own nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj incorporates the perspective of patients, providers, service management and program interpreters to appointments coordination. The main objective of this survey is to understand the perspective of providers Other strategies nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj regarding different aspects of program utilization, impact and satisfaction. If you have any If other, please specify: questions please contact Kimberly Devotta (Research Coordinator) at [email protected] or 416.864.6060 x77496. 2. After the implementation of the Language Services Toronto Program, how often do you use Have you completed the Language Services Toronto Program evaluation survey already? each of the following strategies for dealing with non-English speaking patients? Sometime No nmlkj Yes Never Rarely s Often Always response nmlkj No Assistance of other providers who speak nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj needed language

Assistance of administrative staff who nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Have you used the Language Services Toronto Program to connect with an over-the-phone speak needed language interpreter in the past year? Assistance of other patients who speak nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Yes needed language nmlkj No Other phone interpretation programs nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Face-to-face professional interpreters nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Volunteer language interpreters nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Referrals to other agencies nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj

Asking patients to bring their own nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj interpreters to appointments Other strategies nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj If other, please specify:

Page Page 2 4

Please select the organization where you have used the service: 3. Do you use the Language Services Toronto Program every time you need? Access Alliance Multicultural Health and Community nmlkj Regent Park Community Health Centre nmlkj Yes nmlkj Services nmlkj Rouge Valley Health System nmlkj No nmlkj Alzheimer Society of Toronto nmlkj No response nmlkj Salvation Army Toronto Grace Health Centre nmlkj Baycrest Centre for Geriatric Care nmlkj South Riverdale Community Health Centre nmlkj Bridgepoint Health If no, please select the reasons why? (check all that apply) nmlkj St. Joseph's Health Centre nmlkj Canadian Mental Health Association - Toronto gfedc Technology or equipment challenges nmlkj St. Stephen's Community House nmlkj Central Toronto Community Health Centre gfedc Wait time to connect to interpreter nmlkj Stonegate Community Association nmlkj Centre for Addiction and Mental Health (CAMH) gfedc Cost of interpretation nmlkj Storefront Humber Inc. nmlkj Flemingdon Health Centre gfedc Convenience of other method nmlkj Taddle Creek Family Health Team nmlkj Four Villages Community Health Centre gfedc Patient preference Toronto Central Community Care Access Centre gfedc Phone not appropriate modality for type of visit nmlkj Guelph General Hospital nmlkj (Toronto Central CCAC) gfedc Other nmlkj Holland Bloorview Kids Rehab nmlkj Toronto East General Hospital If other, please specify: nmlkj Hospital for Sick Children (SickKids) nmlkj Unison Health and Community Services nmlkj Humber Community Seniors' Services Inc. nmlkj University Health Network (UHN) nmlkj Humber River Regional Hospital nmlkj West Park Healthcare Centre nmlkj Jean Tweed Treatment Centre nmlkj West Toronto Support Services for Seniors 4. How has the use of the Language Services Toronto Program impacted the following aspects of health care provision for patients that used the program? Mount Sinai Hospital William Osler Health System nmlkj nmlkj Neither nmlkj North York General Hospital nmlkj Women's Health in Women's Hands Significan improved Significan nmlkj Parkdale Community Health Centre nmlkj Women's College Hospital tly nor decre Decrease tly decrea No improved Improved ased d sed response nmlkj Providence Healthcare nmlkj WoodGreen Community Services Patient's privacy nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Patient's autonomy nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Patient's comfort level nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Your relationship with your patients nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj The disclosure of patients (e.g. do you feel the patient provides a more or less nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj complete history?) Patient access to your organization nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Patient engagement nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Overall quality of care nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj

30 5. If the Language Services Toronto Program was cut, what would be the impact to your Page organization? (check all that apply) Page DEMOGRAPHICS 5 gfedc Increased financial cost to offer interpretation 7 gfedc Increased difficulty for staff to engage patients gfedc Decreased use of phone interpretation 10. What is your current position (occupation)? gfedc Decreased quality of care nmlkj Doctor gfedc Decreased efficiency of care (time) nmlkj Nurse gfedc Patient access to care would be compromised nmlkj Social Worker Impact on reputation of organization (organization would no longer be seen as accessible to non-English nmlkj Other gfedc speaking patients) nmlkj No response gfedc Momentum to collaborate with other sites would be compromised If other, please specify: gfedc No impact to my organization gfedc Other gfedc No response If other, please specify: 11. How many years have you worked in your organization?

6. How satisfied are you with the following aspects of the over-the-phone interpretation provided 12. How many years have you worked in your current occupation/role at any organization? by Language Services Toronto Program? Neither satisfied Very nor dissat Dissatisfi Very diss No 13. What is your gender? satisfied Satisfied isfied ed atisfied response nmlkj Male Quality of interpretation nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Female Professionalism of interpreters nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Transgender nmlkj Other Availability of interpreters in needed nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj No response languages Wait times nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj 14. What is your age? Technology and equipment availability nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj 18-24 Training to use the program nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj 25-34 nmlkj 35-44 Program reference materials nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj 45-54 TC LHIN leadership nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj 55-64 Program coordination/management nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj 65+ nmlkj No response Confidentiality of interpretation nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj

Overall, how satisfied are you with the nmlkj nmlkj nmlkj nmlkj nmlkj nmlkj Language Services Toronto Program? If you would like to be entered into a draw to win an iPad mini, please provide the following information: Name:

Email address:

Telephone number:

Submitted information will only be used to determine and contact the winner.

7. Please choose up to three recommendations for improving the Language Services Toronto Page Program? Page gfedc Improve training of interpreters (includes professionalism, customer service, medical terminology and 6 logistics of call) 8 gfedc Expansion to video gfedc Expansion to specialists If you would like to include any additional comments related to the Language Services gfedc Increased availability of languages Toronto Program or this evaluation initiative, please do so in the space below: gfedc Increased availability of interpreters gfedc Availability and visibility of needed equipment gfedc Quicker connection to interpreter gfedc Option to choose gender of interpreter gfedc Accommodations for people who are hard of hearing gfedc Time to debrief interpreter gfedc Program expansion to other sites gfedc Decrease cost jump after 30 minutes gfedc Include face-to-face interpreters gfedc No improvements to recommend gfedc Other Thank you for completing the Language Services Toronto Program Evaluation survey. If other, please specify: Please hit the SUBMIT (9) button and you will be redirected to the web page for the Survey Research Unit, St. Michael's Hospital.

8. Are over-the-phone interpreters through the Language Services Toronto Program appropriate for the services you provide?

Somewhat Please state the reason(s) for selecting 'inappropriate' or Appropriat appropriat Inappropri Not No 'somewhat appropriate' e e ate applicable response

Acute Care nmlkj nmlkj nmlkj nmlkj nmlkj

Chronic nmlkj nmlkj nmlkj nmlkj nmlkj Care Mental nmlkj nmlkj nmlkj nmlkj nmlkj Health Care Supportive nmlkj nmlkj nmlkj nmlkj nmlkj Care Other nmlkj nmlkj nmlkj nmlkj nmlkj If other, please specify:

31